ASSISTING PATIENTS with QUITTING A Transtheoretical Model Approach

ASSISTING PATIENTS with QUITTING A Transtheoretical Model Approach
This module focuses on behavioral techniques for helping patients to quit using tobacco. Tobacco use is a complex, addictive behavior. As a result, helping a patient to quit requires a behavioral intervention, not simply a drug. Research shows that adding pharmacotherapy to a behavioral intervention substantially increases patients’ likelihood of quitting (Fiore et al., 2000). Clinicians are educators who routinely interact with patients to discuss health-related issues. With the introduction of pharmaceutical products to aid cessation, clinicians’ potential role for helping patients to quit using tobacco has expanded. It is our job, as educators, to ensure that students in the health professions are equipped for this role. ♪ Note to instructor(s): Rx for Change also provides a parallel (core) module that does not apply the Transtheoretical Model of Change as a framework for assisting patients with quitting. The non-Transtheoretical Model (core) module is more in line with the strategies described in the Clinical Practice Guideline for treating tobacco use and dependence (Fiore et al., 2000), in that this module combines the precontemplation and contemplation stages into one category—patients who are not ready to quit. The treatment strategies for these two stages are quite similar. Fiore MC, Bailey WC, Cohen SJ, et al. (2000). Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service.

CLINICAL PRACTICE GUIDELINE for TREATING TOBACCO USE and DEPENDENCE
Released June 2000 Sponsored by the Agency for Healthcare Research and Quality of the U.S. Public Heath Service with Centers for Disease Control and Prevention National Cancer Institute National Institute for Drug Addiction National Heart, Lung, & Blood Institute Robert Wood Johnson Foundation In June 2000, the U.S. Public Health Service published a Clinical Practice Guideline for treating tobacco use and dependence (Fiore et al., 2000). This guideline, which summarizes more than 6,000 articles from the literature, reaches a consensus on strategies and recommendations designed to assist health care providers in delivering state-of-the-art interventions for smoking cessation. The slides that follow describe feasible, practical, and effective behavioral strategies that clinicians can apply when assisting patients with quitting. These strategies derive from recommendations set forth in the Clinical Practice Guideline. The complete guideline, along with supportive materials, is available at Fiore MC, Bailey WC, Cohen SJ, et al. (2000). Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service.

EFFECTS OF CLINICIAN INTERVENTIONS
Fiore et al. (2000). Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: USDHHS, PHS. 1.0 1.1 (0.9,1.3) 1.7 (1.3,2.1) 2.2 (1.5,3.2) n = 29 studies Compared to smokers who receive no assistance from a clinician, smokers who receive such assistance are 1.7–2.2 times as likely to quit successfully for 5 or more months. Decades of research tell us that clinicians can have an important impact on their patients’ likelihood of achieving cessation. A meta-analysis of 29 studies determined that patients who received a tobacco cessation intervention from a nonphysician clinician or a physician clinician were 1.7 and 2.2 times as likely to quit (at 5 or more months postcessation), respectively, compared with patients who did not receive such an intervention (Fiore et al., 2000). Self-help materials were only slightly better than no clinician. Fiore MC, Bailey WC, Cohen SJ, et al. (2000). Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service.

The CLINICIAN’s ROLE in PROMOTING CESSATION
Tobacco users expect to be encouraged to quit by health professionals. Screening for tobacco use and providing tobacco cessation counseling are positively associated with patient satisfaction (Barzilai et al., 2001). Tobacco users expect to be encouraged to quit by health professionals. In a study examining whether health habit counseling affects patient satisfaction, Barzilai et al. (2001) determined that of 12 health habits examined (exercise, diet, alcohol history, alcohol counseling, tobacco history, tobacco counseling, passive tobacco exposure, contraception and condom use, substance use history, substance use counseling, STD prevention, and counseling about HIV testing or prevention), only tobacco history and tobacco counseling were significantly associated with full satisfaction with the clinician visit. A clinician who does not address tobacco use tacitly implies that quitting is not important. Barzilai DA, Goodwin MA, Zyzanski SJ, Stange KC. (2001). Does health habit counseling affect patient satisfaction? Prev Med 33:595–599. Failure to address tobacco use tacitly implies that quitting is not important. Barzilai et al. (2001). Prev Med 33:595–599.

The 5 A’s ASK ADVISE ASSESS ASSIST ARRANGE
The Clinical Practice Guideline (Fiore et al., 2000) delineates five key components for tobacco cessation interventions. These components, referred to as the 5 A’s, offer a practical method for implementing tobacco counseling in clinical practice. The 5 A’s are as follows: Ask Advise Assess Assist Arrange ♪ Note to instructor(s): The 5 A’s presented in the guideline are a modified form of the National Cancer Institute’s original 5 A’s (Anticipate [tobacco use], Ask, Advise, Assist, and Arrange; Frankowski & Secker-Walker, 1994; Glynn & Manley, 1990). ♪ Note to instructor(s): Throughout this module, ask students to refer to their Tobacco Cessation Counseling Guidesheet_Transtheoretical Model (ancillary handout). The slides in this module are designed to parallel the guidesheet. Fiore MC, Bailey WC, Cohen SJ, et al. (2000). Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service. Frankowski BL, Secker-Walker RH. (1994). Pediatricians’ Role in Smoking Prevention and Cessation (Smoking and Tobacco Control Monograph No. 5; NIH Publication No ). Bethesda, MD: U.S. Department of Health and Human Services, Public Health Service, National Institutes of Health, National Cancer Institute. Glynn TJ, Manley MW. (1990). How to Help Your Patients Stop Smoking: A National Cancer Institute Manual for Physicians (NIH Publication No ). Bethesda, MD: U.S. Department of Health and Human Services, Public Health Service, National Institutes of Health, National Cancer Institute. ASSESS ASSIST ARRANGE HANDOUT Fiore et al. (2000). Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: USDHHS, PHS.

The 5 A’s (cont’d) ASK Ask about tobacco use
“Do you ever smoke or use any type of tobacco?” “I take time to ask all of my patients about tobacco use—because it’s important.” “Medication X often is used for conditions linked with or caused by smoking. Do you, or does someone in your household smoke?” “Condition X often is caused or worsened by smoking. Do you, or does someone in your household smoke?” ASK Ask. Tobacco smoke has the potential to interact with many medications, altering both drug levels and efficacy. Tobacco use also can induce early onset of disease and exacerbate existing medical conditions. It is appropriate, if not essential, for clinicians to assess and document each patient’s tobacco use status, preferably at each visit. Asking about tobacco use should be considered to be as important as evaluating vital signs during a routine medical screening, and when obtaining a medication history, clinicians should ask about tobacco in the same way that they would ask about any other drug. Clinicians also should consider including a query about tobacco use on the new patient profile form. At a minimum, the form should assess tobacco use status (i.e., current, former, never). Appropriate language for assessing tobacco use status would be: “Do you ever smoke or use any type of tobacco?” This question will capture not only cigarette smoking but all forms of tobacco use. The query also can be linked to the clinician’s knowledge of a patient’s disease status or medication profile. For example: “Medication X often is used for conditions linked with or caused by smoking. Do you, or does someone in your household smoke?” or “Condition X often is caused or worsened by smoking. Do you, or does someone in your household smoke?” When clinicians ask about tobacco use, it is important that they take a genuine and sensitive approach, conveying concern for their patients’ well-being. A judgmental tone likely will not result in accurate disclosure of tobacco use.

The 5 A’s (cont’d) ADVISE
tobacco users to quit (clear, strong, personalized, sensitive) “It’s important that you quit as soon as possible, and I can help you.” “I realize that quitting is difficult. It is the most important thing you can do to protect your health now and in the future. I have training to help my patients quit, and when you are ready, I will work with you to design a specialized treatment plan.” ADVISE Advise. It is the clinician’s responsibility to assist patients in improving their health. Patients who use tobacco should be strongly advised to quit. At the very least, these patients should be advised to consider quitting. The message should be clear and strong, yet personalized and sensitive. The message must be delivered without judgment—or the clinician will likely waste that “teachable moment” and potentially alienate his or her patient. Tone and manner should convey a concern for the patient’s well-being as well as a commitment to help him or her quit—when the patient is ready. Consider the following statements: “It’s important that you quit as soon as possible, and I can help you.” “I realize that quitting is difficult. It is the most important thing you can do to protect your health now and in the future. I have training to help my patients quit, and when you are ready, I will work with you to design a specialized treatment plan.” The clinician can personalize the message by tying tobacco use to current health or illness; its social and economic costs; the patient’s motivation level and readiness to quit; or the impact of tobacco use on children, others in the household and in their environment, and pets. For example: “If you continue to smoke, your [disease] will worsen/fail to improve.” Using a genuine and sensitive approach that acknowledges the difficulty of what is being requested, the clinician might move the patient forward in the process of preparing to quit.

The 5 A’s (cont’d) ASSESS Assess readiness to make a quit attempt
Assist with the quit attempt Not ready to quit: provide motivation (the 5 R’s) Ready to quit: design a treatment plan Recently quit: relapse prevention ASSIST Assess. After the clinician advises the patient to quit, the next step is to assess the patient’s readiness, or willingness, to try to quit. Is the patient considering quitting in the next month? Or did he or she quit recently? Assist. The patient’s readiness to try to quit will define the next course of action, which is delivering an intervention tailored to his or her needs. By being a good listener and gathering appropriate information, the clinician can tailor the interventions effectively. A patient who is not ready to quit will receive a very different type of intervention than will one who is ready to quit in the upcoming weeks. For the patient who is not ready to quit (in the precontemplation or contemplation stage of change), a motivational intervention should be provided, by applying the 5 R’s (to be discussed later). If the patient is ready to quit in the next 30 days (in the preparation stage), a treatment plan should be designed, including counseling and pharmacotherapy (except when contraindicated). The clinician could suggest that the patient enroll in a structured, intensive tobacco cessation program, to increase the likelihood of quitting—this is particularly important for persons who are at high risk of relapse or for patients who are highly dependent, refractory smokers (i.e., having made multiple serious quit attempts). Other patient populations that might be particularly well suited for structured programs include adolescent smokers, pregnant smokers, and patients with coexisting psychiatric conditions. A patient who recently quit (i.e., in the past 6 months; in the action stage of change) will need continued support and encouragement, and reminders regarding the need to abstain from all tobacco use—even a puff. A patient who has been off of tobacco for more than 6 months (in the maintenance stage of change) typically is relatively stable but often needs to be reminded to remain vigilant for potential triggers for relapse.

PROVIDE ASSISTANCE THROUGHOUT THE QUIT ATTEMPT
The 5 A’s (cont’d) Arrange follow-up care ARRANGE Number of sessions Estimated quit rate* 0 to 1 12.4% 2 to 3 16.3% 4 to 8 20.9% More than 8 24.7% Arrange. The clinician should make certain to arrange for follow-up care and patient monitoring. With each contact, it is important to document the counseling session. These records can provide a starting point for subsequent discussions. Follow-up visits can be arranged in several ways. For example, the clinician can do the following: “Check in” with the patient when he or she next returns. Schedule specific follow-up visits to discuss tobacco cessation. Invite the patient to enroll in a tobacco cessation group with which the clinician is affiliated. With prior approval, call the patient at home to see how he or she is progressing. (If a message is left, the clinician should not indicate that he or she is calling regarding a quit attempt—this might be private information that the patient does not want others to hear.) Document key dates (e.g., quit dates, tobacco-free anniversaries); acknowledge important milestones. A follow-up contact should be scheduled within the first week after the quit date. The next follow-up is recommended within the first month. Further follow-up contact should be scheduled as needed or indicated. During the follow-up contacts, the patient should be congratulated for success. If tobacco use has occurred, the circumstances should be reviewed and a commitment sought to return to total abstinence. The patient should be reminded that lapses (slips) occur as part of the normal learning process and should be viewed as such. Pharmacotherapy use should be assessed, including compliance and side effects experienced. When appropriate, referral to more intensive treatment should be considered. According to the Clinical Practice Guideline (Fiore et al., 2000), multiple patient contacts are associated with higher quit rates. The estimated quit rates, based on number of treatment sessions (i.e., counseling contact sessions) are presented in this slide. Even brief interventions (i.e., asking about tobacco use and advising to quit) can increase patients’ readiness to quit. In a meta-analysis of 17 trials assessing the effects of cessation advice from medical practitioners (Lancaster & Stead, 2004), brief advice was associated with an increased likelihood of quitting (odds ratio, 1.74) versus no advice (or usual care), which is equivalent to an absolute change in cessation rate of 2.5%; in addition, more intensive advice led to a higher likelihood of quitting when compared to more minimal advice (odds ratio, 1.44). ♪ Note to instructor(s): A dose-response relationship also exists for the counseling session length and the total amount of contact time (combining across treatment sessions). The greater the amount of time spent with the patient, the more likely the patient is to achieve abstinence (Fiore et al ). Fiore MC, Bailey WC, Cohen SJ, et al. (2000). Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service. Lancaster T, Stead L. (2004). Physician advice for smoking cessation. Cochrane Database Syst Rev (4):CD * 5 months (or more) postcessation PROVIDE ASSISTANCE THROUGHOUT THE QUIT ATTEMPT Fiore et al. (2000). Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: USDHHS, PHS.

READINESS to make a quit attempt
The 5 A’s: REVIEW ASK about tobacco USE ADVISE tobacco users to QUIT As a final review, the 5 A’s are as follows: Ask about tobacco use. Advise tobacco users to quit. Assess readiness to make a quit attempt. Assist with the quit attempt. Arrange follow-up care. Each of these is a key component of comprehensive tobacco cessation counseling interventions. ASSESS READINESS to make a quit attempt ASSIST with the QUIT ATTEMPT ARRANGE FOLLOW-UP care

The (DIFFICULT) DECISION to QUIT
Faced with change, most people are not ready to act. Change is a process, not a single step. Typically, it takes multiple attempts. Historically, clinicians have been trained to provide action-oriented, “just do it” counseling interventions. It’s important to recognize that not all patients have the same level of commitment, or readiness, to take action. When faced with change, most people (about 70%) are not ready to act (Prochaska et al., 1992). Patients at different stages of readiness to quit require different kinds of interventions. Counseling can be tailored to patients’ readiness to quit (their “stage of change”). This is particularly important when counseling through various steps of tobacco cessation. Consider the following: Some patients are determined smokers…they might never quit! Some might know that they need to quit but have tried and failed so many times that they have no confidence in their ability to quit. Some are considering quitting but might not have gathered the courage or information necessary to make a serious quit attempt. Some will be ready to set a quit date. Others might have stopped recently but remain highly vulnerable to relapse. And some will have been smoke-free for at least 6 months yet remain at risk for relapse. In most cases, behavior change is a process, not a single step. The process ranges from not thinking about making a change to successful implementation of a behavioral change over a sustained period of time. Typically, it takes multiple attempts before success is achieved. Prochaska JO, DiClemente CC, Norcross JC. (1992). In search of how people change: Applications to addictive behaviors. Am Psychol 47:1102–1114. HOW CAN I LIVE WITHOUT TOBACCO?

HELPING SMOKERS QUIT IS a CLINICIAN’S RESPONSIBILITY
TOBACCO USERS DON’T PLAN TO FAIL. MOST FAIL TO PLAN. Clinicians have a professional obligation to address tobacco use and can have an important role in helping patients plan for their quit attempts. Tobacco users don’t plan to fail in their quit attempts. But most fail to plan. Health care providers have a professional obligation to help patients improve their health. This includes addressing tobacco use and helping patients to quit. Clinicians serve as facilitators in the process, calling attention to the need to quit, advising patients to quit, assisting with the quit attempt, and monitoring patient progress over time. For current smokers, the goal is to move tobacco users forward in their decision to quit. However, the decision to quit ultimately lies in the hands of the patient. THE DECISION TO QUIT LIES IN THE HANDS OF EACH PATIENT.

ASSESSING READINESS to QUIT
Patients differ in their readiness to quit. STAGE 1: Not thinking about changing anytime soon STAGE 2: Considering changing, but not yet Prior to providing assistance with tobacco cessation, it is helpful to assess each patient’s readiness to quit (Fiore et al., 2000; Prochaska & DiClemente, 1984; Prochaska et al., 1992). When people need to change a health behavior, it typically isn’t a spontaneous decision. Change is a process. Research has shown that there are five stages in the overall process of change. These stages apply to many behaviors, not just tobacco use: STAGE 1: Not thinking about changing in the foreseeable future. STAGE 2: Considering changing, but not in the immediate future. STAGE 3: Getting ready to change soon. STAGE 4: In the process of change. STAGE 5: Changed a while ago and has fully implemented the change. Fiore MC, Bailey WC, Cohen SJ, et al. (2000). Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service. Prochaska JO, DiClemente CC. (1984). The Transtheoretical Approach: Crossing Traditional Boundaries of Therapy. Homewood, IL: Dow Jones-Irwin. Prochaska JO, DiClemente CC, Norcross JC. (1992). In search of how people change: Applications to addictive behaviors. Am Psychol 47:1102–1114. STAGE 3: Getting ready to change soon STAGE 4: In the process of changing STAGE 5: Changed a while ago

ASSESSING READINESS to QUIT (cont’d)
STAGE 1: Precontemplation STAGE 2: Contemplation More specifically, these stages of change are referred to as follows: Precontemplation: not thinking about changing in the next 6 months. Contemplation: considering changing in the next 6 months, but not in the next 30 days. Preparation: ready to change in the next month. Action: in the process of change (but implemented the change less than 6 months ago). Maintenance: has fully implemented the change for more than 6 months. The action stage (e.g., behavior change) is not the first step for most patients. In most cases, other stages must be successfully traversed before action can occur. Of current smokers, approximately 50–60% are in precontemplation, 30–40% are in contemplation, and only 10–15% are in the preparation stage (Prochaska et al., 1992), although these values vary by region of the country and by country. The amount of time spent in a specific stage will vary by patient—for example, some patients will be in contemplation for years (a chronic contemplator). Others might move very quickly from precontemplation to preparation and so on. Assessing a patient’s readiness to quit enables clinicians to deliver relevant, appropriate counseling messages. The goal of interventions at each stage is to move patients forward, helping them to develop readiness for permanent change. Patients in different stages will require different types of interventions. For example, a person who is in the precontemplation stage will need a very different type of intervention than will a person who is in the action stage. Determining each patient’s stage of change will save clinician time and patient time by ensuring that the intervention is appropriate for the patient’s needs at the time of the interaction. Tailored communications have been shown to be effective in promoting smoking cessation, even when tailored materials are delivered at a population level, with long-term point-prevalence abstinence rates of 22–26% (Velicer et al., 2006). Prochaska JO, DiClemente CC, Norcross JC. (1992). In search of how people change: Applications to addictive behaviors. Am Psychol 47:1102–1114. Velicer WF, Prochaska JO, Redding CA. (2006). Tailored communications for smoking cessation: past successes and future directions. Drug Alc Rev 25:49–57. STAGE 3: Preparation STAGE 4: Action STAGE 5: Maintenance Assessing a patient’s readiness to quit enables clinicians to deliver relevant, appropriate counseling messages.

STAGES of CHANGE: A LINEAR VIEW
Quit date This diagram depicts the relationship between the stages of change as a function of time. - 6 months - 30 days + 6 months Precontemplation Contemplation Action Maintenance Preparation

Assess readiness to quit (or to stay quit) at each patient contact.
ASSESSING READINESS to QUIT (cont’d) For most patients, quitting is a cyclical process, and their readiness to quit (or stay quit) will change over time. Not ready to quit This diagram emphasizes that behavior change is a process. Over time, patients often cycle into and out of the different stages. They might quit for a while, then return to tobacco use before they quit again for good. This movement between the stages is normal and is to be expected, particularly for an addictive behavior that patients know they need to stop but might not have the time, energy, or will to stop at the present time. For this reason, it is important to determine the patient’s readiness to commit to quitting at each contact. Do not assume that patients who inquire about quitting are ready to quit. Commonly, they are just thinking about it and gathering information. Similarly, do not assume that a patient who asks for a prescription for bupropion or nicotine replacement therapy or who presents at a pharmacy to purchase these medications is ready to quit. Learning about the different stages of readiness to quit will help clinicians gain a better understanding of why it is important to think of behavior change as a process, not an event. For most people, the process of quitting is characterized by a series of quit attempts and subsequent relapses—on average, former smokers report 10.8 quit attempts over a period of 18.6 years before quitting for good (Hazelden Foundation, 1998). Hazelden Foundation. (1998). Survey on current and former smokers—1998. Center City, MN: Hazelden Foundation. Retrieved December 31, 2006, from Pre- Maintenance Relapse* contemplation Action Contemplation Assess readiness to quit (or to stay quit) at each patient contact. Preparation

IS a PATIENT READY to QUIT?
Does the patient now use tobacco? Yes No This flow chart, which is presented in the Clinical Practice Guideline for treating tobacco use and dependence (Fiore et al., 2000), describes how to determine a patient’s readiness to quit and the general types of interventions that should be applied. Treatment for patients who are ready to quit should include all five of the key counseling components (the 5 A’s). Fiore MC, Bailey WC, Cohen SJ, et al. (2000). Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service. Is the patient ready to quit now? Did the patient once use tobacco? No Yes Yes No Precontemplation - or - Contemplation Preparation Action - or - Maintenance Never smoker

ASSESSING READINESS to QUIT (cont’d)
STAGE 1: Precontemplation Not thinking about quitting in the next 6 months Some patients are aware of the need to quit. These struggle with ambivalence about change. Patients are not ready to change, yet. Pros of continued tobacco use outweigh the cons. The first stage in the continuum of change is precontemplation. In the precontemplation stage, patients aren’t considering making a change in the foreseeable future (usually defined as in the next 6 months). The 6-month criterion is recommended by experts in the field because that is about as far into the future as people make plans to change their behavior (Prochaska & Goldstein, 1991). Patients belonging to this stage fall into two general categories: Those who are not aware of any need to change—the problem is not yet on their radar screen. Those who are unwilling or unable to change—commonly because they are defensive about their negative health behavior or because they are too discouraged to change (perhaps because of prior failed attempts). Health care providers commonly label patients in this stage as difficult or unmotivated. Many of these patients simply are not ready. They struggle with ambivalence and see the pros (positive effects) of tobacco use as being more important than the cons (negative effects). The goal of intervention at this stage is to move patients into the next stage: contemplation. If a patient is ready to move to the action stage, this should not be discouraged, but patients should not be forced to move more quickly than they are comfortable with. Prochaska JO, Goldstein MG. (1991). Process of smoking cessation. Clin Chest Med 12:727–735. GOAL: Move the patient into the contemplation stage.

STAGE 1: PRECONTEMPLATION Counseling Strategies
DOs Strongly advise to quit Provide information Ask noninvasive questions; identify reasons for tobacco use “Envelope” Raise awareness of health consequences/concerns Demonstrate empathy, foster communication Leave decision up to patient DON’Ts Persuade “Cheerlead” Tell patient how bad tobacco is, in a judgmental manner Provide a treatment plan Patients in the precontemplation stage might be defensive or resistant to interventions that would require them to take action right away. When counseling a patient who is in the precontemplation stage, it is important to demonstrate understanding and empathy, to foster ongoing communication, and to ask questions noninvasively. Instead of pressuring the patient for an immediate behavioral shift, gently raise the patient’s awareness of the health consequences of continued tobacco use. Messages that either emphasize the cons of tobacco use or deemphasize the pros of tobacco use help move the patient forward in the process of change. It is useful to tailor messages based on the patient’s health history, such as highlighting how tobacco use can induce early onset of particular diseases for which the patient may be at risk, or how it can exacerbate existing conditions. An approach that might be effective with parents is discussing how smoking can negatively affect their children’s health and increase the likelihood that their children will grow up to be smokers. Strongly encourage patients to quit, yet emphasize that the decision to quit, or not to quit, is theirs. To gauge a patient’s level of resistance to quitting, ask him or her, “If I were to give you an envelope, what would the message inside need to say for you to consider quitting?” If the patient says, “There is nothing that you could write that would make me consider quitting,” then there is little that you can do at this point, except to (1) stress the importance of quitting for the patient’s health, (2) suggest that the patient not rule out the possibility of quitting, and (3) offer to assist the patient with quitting, should the patient change his or her mind. Also, asking patients what brand they smoke and whether they buy tobacco in large quantities can provide insight regarding a patient’s likelihood of being ready to quit. Aggressive efforts to persuade the patient into making a change are not advisable during this stage. Likewise, high-spirited “cheerleading” may only heighten the patient’s resistance at this stage. Also, be careful not to use a judgmental approach in telling patients that tobacco is bad for them. It is not yet time to provide a treatment plan, although it might be useful to inform patients of the various options available. Offer assistance. Make it clear that it is an ongoing, standing offer, which the patient can accept whenever he or she is ready.

GOAL: Move the patient into the preparation stage.
ASSESSING READINESS to QUIT (cont’d) STAGE 2: Contemplation Considering quitting in the next 6 months but not in the next 30 days Patients are aware of the need to quit. They are aware of the benefits of quitting. But they struggle with ambivalence about change. The second stage in the continuum of change is contemplation. During the contemplation stage, patients are considering taking steps to change their behavior in the near future (typically within the next 6 months). They recognize the need to change. They are aware of the benefits offered by change. But they struggle with ambivalence about change. Patients in the contemplation stage will be more interested in discussing quitting than will patients in precontemplation, and they will be more receptive to a clinician’s offer to help them quit. These patients might express guilt or shame about their inability to quit. Tobacco use is a highly stigmatized behavior, and people are very aware of the negative health consequences of tobacco use. As a result, many tobacco users are in the contemplation stage for quitting. They know they need to quit, they are thinking about it, but they are not yet ready or able to commit to the quit attempt. GOAL: Move the patient into the preparation stage.

STAGE 2: CONTEMPLATION Counseling Strategies
DOs Strongly advise to quit Provide information Identify reasons for tobacco use Demonstrate empathy; increase motivation Encourage self-reevaluation of concerns Offer encouragement DON’Ts Persuade “Cheerlead” Tell patient how bad tobacco is, in a judgmental manner Provide a treatment plan Provide information and education about the products available to help the patient quit and about the quitting process more broadly. Strongly advise the patient to quit. Assess the patient’s reasons for continued tobacco use, as well as reasons why he or she is not ready to quit at this time. Demonstrate empathy for the patient’s struggle and encourage or motivate the patient to move to the next stage (preparation). Express optimism in your ability to make the patient’s next quit attempt successful. Encourage the patient to reevaluate his or her concerns about prolonged tobacco use. Bringing these issues to the forefront of their thinking may help some patients to move forward in their readiness to quit. Although a patient in the contemplation stage may be closer to making a behavioral shift than during the precontemplation stage, it’s nevertheless premature to attempt action-oriented interventions at this point. A poorly timed intervention could meet with renewed resistance, because the patient is not yet equipped to jump into the action stage. Many patients are “chronic contemplators”—they consider quitting but never act on it. While considering, they often seek information, strategies, and suggestions for reducing the level of struggle they feel prevents them from making a quit attempt. Health care providers can act as agents for change by assuming the role of educational informant to contemplators. Also, for chronic contemplators, it is useful to help them to take small steps toward quitting that will result in them behaving more like persons in the preparation stage. For example, you might recommend that they attempt to delay their first cigarette in the morning by 30 minutes, cut down the number of cigarettes they smoke per day, or go for 24 hours without smoking.

NOT READY TO QUIT: Counseling Strategies (cont’d)
The 5 R’s—Methods for increasing motivation: Relevance Risks Rewards Roadblocks Repetition Tailored, motivational messages For patients who are in either the precontemplation or contemplation stage, clinicians can deliver tailored, motivational messages by applying the 5 R’s: Relevance: Encourage the patient to indicate why quitting is personally relevant. Be as specific as possible. Motivational information has the most impact if it is relevant to the patient’s disease status or risk, family or social situation (e.g., having children in the home), health concerns, age, sex, and other important patient characteristics (e.g., prior quitting experience, personal barriers to cessation). Risks: Ask the patient to identify consequences of tobacco use. Suggest and highlight those that seem most relevant to the patient and emphasize that other forms of tobacco (such as smokeless, or lower-tar-level cigarettes) will not eliminate the risks. Risks of tobacco use are discussed in the Epidemiology of Tobacco Use and Pathophysiology of Tobacco-Related Disease modules. Rewards: Ask the patient to identify benefits of quitting. Highlight those that seem relevant to the patient. Examples of benefits of cessation are discussed in the Epidemiology of Tobacco Use module. Roadblocks: Ask the patient to identify barriers to quitting and potential methods for circumventing each barrier. Suggest and highlight those that seem most relevant to the patient. Common barriers include withdrawal symptoms, fear of failure, weight gain, lack of support, depression, and enjoyment of tobacco. Repetition: Repeat the motivational intervention whenever possible. Tobacco users who have failed in previous quit attempts should be reminded that most people make repeated quit attempts before they are successful. Fiore MC, Bailey WC, Cohen SJ, et al. (2000). Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service. Fiore et al. (2000). Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: USDHHS, PHS.

COUNSELING a PATIENT who is NOT READY TO QUIT: A Demonstration
CASE SCENARIO: MS. STEWART ♪ Note to instructor(s): After presenting this slide (read the case scenario to the audience), enact Case Scenario A by either (1) showing Video #1 or (2) having students role-play this case scenario in front of the class. If you choose option (2), it is best to select students in advance, and provide them with the instructor guidelines for this case. Have one student play the patient and one student play the clinician. Appropriate dialogue is provided in the instructor guidelines. The two slides that follow can be used as “case debriefing” aids. Case B also is provided for instructors who would like to enact two different scenarios. ♪ Note to instructor(s): Video #1 is a pharmacy-based counseling session, but similar strategies should be used, regardless of clinician type or setting. You are a clinician providing care to Ms. Stewart, a 55-year-old patient with emphysema. She uses two different inhalers for her emphysema.

NOT READY to QUIT: Case Scenario Synopsis
Ask about tobacco use Link inquiry to knowledge of disease Assess readiness to quit Aware of need to quit; not ready yet Advise to quit Discuss implications for disease progression “I will help you, when you are ready” Note the following key points about this scenario: The clinician used knowledge of the patient’s disease state to initiate the conversation about tobacco use. The clinician assessed the patient’s interest in quitting and explored the patient’s beliefs about her ability to quit, as well as some of the perceived benefits of and barriers to quitting. The clinician expressed concern about the patient’s health, informed the patient that her smoking will worsen her condition, and advised the patient to quit. The clinician offered to assist the patient, should she decide to quit.

NOT READY to QUIT: Case Scenario Synopsis (cont’d)
The clinician has Established a relationship Established herself as a resource Planted a seed to move patient forward Opened a door to facilitate further counseling The clinician has provided an appropriate intervention for a patient who is not ready to quit. The goal was to try to plant a seed to get the patient thinking about quitting, to move the patient forward in the process of change. And, in doing so, the clinician has fostered communication and a relationship with one of his or her patients. Note that this brief, motivational intervention required very little time (approximately 2 minutes).

GOAL: Achieve cessation.
ASSESSING READINESS to QUIT (cont’d) STAGE 3: Preparation Ready to quit in the next 30 days Patients are aware of the need to, and the benefits of, making the behavioral change. Patients are getting ready to take action. The third stage in the continuum of change is preparation. Patients in the preparation stage are ready to quit in the next 30 days. These patients recognize the need to change and the benefits to be had by quitting. They are getting ready to take action. Often, they might have made a quit attempt in the past year. For patients in the preparation stage, the cons of tobacco use begin to outweigh the pros of tobacco use. Patients in the preparation stage generally have more confidence in their ability to quit than do patients in the precontemplation or contemplation stages. The goal is to assist these patients in achieving cessation. GOAL: Achieve cessation.

STAGE 3: PREPARATION Three Key Elements of Counseling
Assess tobacco use history Discuss key issues Facilitate quitting process Three key elements of tobacco cessation counseling: Assess tobacco use history Discuss key issues Facilitate the quitting process Assessing tobacco use history and discussing key issues are important information-gathering steps of counseling. Clinicians must develop an understanding of their patients’ unique history and perspective on tobacco use before facilitating the quitting process. ♪ Note to instructor(s): These three elements parallel those presented on the Tobacco Cessation Counseling Guidesheet_Transtheoretical Model (ancillary handout).

STAGE 3: PREPARATION Assess Tobacco Use History
Praise the patient’s readiness Assess tobacco use history Current use: type(s) of tobacco, brand, amount Past use: duration, recent changes Past quit attempts: Number, date, length Methods used, compliance, duration Reasons for relapse This stage represents a window of opportunity for helping a patient make a quit attempt. Clinicians should do the following prior to making treatment recommendations: Praise the patient’s readiness to quit. Assess tobacco use history, including current use, past use, and history of quit attempts: Current use of tobacco: What types of tobacco are used? What brand? How much? Past use of tobacco: How long has the patient been using tobacco? Has the patient changed his or her level of tobacco use recently? Past quit attempts: How many quit attempts has the patient made, how long was he or she off of tobacco, and when was the last quit attempt? What methods were used? What worked? What didn’t work? If medications were used, how were they used? What factors contributed to relapse (e.g., medication noncompliance, situational factors)? Identifying reasons for relapse can provide important information for an upcoming quit attempt.

STAGE 3: PREPARATION Discuss Key Issues
Reasons/motivation to quit (or avoid relapse) Confidence in ability to quit (or avoid relapse) Triggers for tobacco use What situations lead to temptations to use tobacco? What led to relapse in the past? Routines/situations associated with tobacco use Key issues to address include the following: Discuss reasons and motivations for wanting to quit. Ask the patient to think about why it is important, to him or her, to adopt a tobacco-free lifestyle. What are the patient’s motivations for wanting to quit? Discuss whether the patient has concerns about the effects of second-hand smoke on others. How confident is the patient in his or her ability to quit? Ideally, the patient will be highly confident, but many will lack confidence because of previously failed attempts. By providing additional support and working with the patient in designing the treatment plan, a clinician can infuse confidence into the patient. It will be “different,” this time, because the patient will be more prepared. Discuss specific triggers for tobacco use. Triggers might include negative affect, being around other smokers, meal times, alcohol or coffee consumption, cravings for tobacco, time pressures, or other situations such as celebrating with others. Triggers should be identified prior to quitting, while the patient is still smoking “normally.” Encourage patients to think about the times and places where they smoke or use tobacco, each time they do so. This provides important insight into a person’s tobacco use behavior, including the circumstances that underlie the need or desire for tobacco. Having a clear understanding of the behavior will help a person to be more effective when attempting to change it. Determine whether there are certain routines or situations that the patient associates with tobacco use (e.g., when drinking coffee, while driving in the car, while bored or stressed, after meals, after sex). Does the patient use tobacco in response to stress? What types of triggers or situations invoke stress-related tobacco use? Assess whether the patient has a social network of friends, family, and coworkers that is supportive of the quit attempt. Encourage the patient to enlist the support of others; invite significant other to attend cessation counseling sessions. Encourage the patient’s housemates who are tobacco users to quit simultaneously. Assess whether the patient is concerned about postcessation weight gain. Advise the patient to quit first, then work on weight maintenance a month or more later. However, if concern about weight gain is a barrier to quitting, then it should be addressed simultaneously with the quit attempt. Discuss any concerns that the patient might have about withdrawal symptoms. When drinking coffee While driving in the car When bored or stressed While watching television While at a bar with friends After meals During breaks at work While on the telephone While with specific friends or family members who use tobacco

STAGE 3: PREPARATION Discuss Key Issues (cont’d)
Stress-Related Tobacco Use THE MYTHS THE FACTS “Smoking gets rid of all my stress.” “I can’t relax without a cigarette.” There will always be stress in one’s life. There are many ways to relax without a cigarette. Stress is often cited as the primary reason for smoking. This slide presents the myths versus the facts. Smokers often confuse the relief of their nicotine withdrawal with the feeling of relaxation. The goal is to help patients to realize that tobacco is the problem, not the solution. Smokers confuse the relief of withdrawal with the feeling of relaxation. STRESS MANAGEMENT SUGGESTIONS: Deep breathing, shifting focus, taking a break.

Social Support for Quitting ADVISE PATIENTS TO DO THE FOLLOWING: Ask family, friends, and coworkers for support, for example, not to smoke around them and not to leave cigarettes out Talk with their health care provider Get individual, group, or telephone counseling The Clinical Practice Guideline (Fiore et al., 2000) cites both intra- and extra-treatment social support as key ingredients for quitting. Advise patients to do the following: Ask family, friends, and coworkers for support, for example, not to smoke around them and not to leave cigarettes out. Talk with their health care provider. Get individual, group, or telephone counseling support. Programs often are provided at local hospitals and health centers. Tobacco cessation counseling is available, to all Americans, by calling QUIT-NOW. Patients who receive social support and encouragement enhance their odds of quitting successfully. Fiore MC, Bailey WC, Cohen SJ, et al. (2000). Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service. Patients who receive social support and encouragement are more successful in quitting.

Most smokers gain fewer than 10 pounds, but there is a wide range.
HERMAN ® is reprinted with permission from LaughingStock Licensing Inc., Ottawa, Canada All rights reserved. Most smokers gain fewer than 10 pounds, but there is a wide range. Postcessation weight gain is an important consequence of tobacco cessation that often is also a barrier to quitting. The majority of tobacco users gain weight after quitting. Studies suggest that most quitters will gain less than 10 pounds, but a broad range of weight gains have been reported, with up to 10% of quitters gaining as much as 30 pounds (Fiore et al., 2000). In a study of nearly 6,000 smokers who were followed for 5 years after quitting, the mean weight gain during the follow-up period was 19.2 pounds and 16.7 pounds among women and men, respectively (O’Hara et al., 1998). The weight- suppressing effects of tobacco are well known. However, the mechanisms to explain why most successful quitters gain weight are not completely understood. Smokers have been found to have an approximately 10% higher metabolic rate compared with nonsmokers (Perkins, 1992). Higher caloric intakes have been documented after cessation (Hatsukami et al., 1993), and it has been speculated that the increased caloric intake might be caused either by an increase in appetite or by quitters eating more because the taste buds have become more receptive after cessation and foods taste better (Hamilton et al., 1992). Fiore MC, Bailey WC, Cohen SJ, et al. (2000). Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service. Hamilton E, Whitney E, Sizer F. (1992). Nutrition:Concepts and Controversies, 6th ed. St. Paul: West Publishing. Hatsukami D, LaBounty L, Hughes J, Laine D. (1993). Effects of tobacco abstinence on food intake among cigarette smokers. Health Psychol 12:499–502. O'Hara P, Connett JE, Lee WW, Nides M, Murray R, Wise R. (1998). Early and late weight gain following smoking cessation in the Lung Health Study. Am J Epidemiol 148:821–830. Perkins KA. (1992). Metabolic effects of cigarette smoking. J Appl Physiol 72:401–409.

Concerns about Weight Gain Discourage strict dieting while quitting Recommend physical activity Encourage healthful diet, planning of meals, and inclusion of fruits Suggest increasing water intake or chewing sugarless gum Recommend selection of nonfood rewards Maintain patient on pharmacotherapy shown to delay weight gain Refer patient to specialist or program Many patients will be concerned about weight gain after quitting; these patients should be discouraged from strict dieting while quitting (Fiore et al., 2000). To reduce weight gain, patients can engage in regular physical activity and adhere to a healthful diet (as opposed to strict dieting). Patients should carefully plan and prepare meals to avoid binge eating, increase fruit and water intake to create a feeling of fullness, and chew sugarless gum or eat sugarless candies. Advise patients to select nonfood rewards. Consider maintaining these patients on pharmacotherapy that has been shown to delay weight gain, such as nicotine gum or bupropion. Patients also can be referred to a dietary specialist or weight maintenance program. ♪ Note to instructor(s): Research studies have shown that patients who attempt to modify their diet at the same time as quitting smoking are less likely to succeed in smoking cessation than are patients who just try to quit smoking. We recommend that clinicians advise most of their patients to quit smoking first, then work on issues of weight gain. The average gain of less than 10 pounds is less detrimental to one’s health than is smoking, but it is not prudent for clinicians to overlook patients’ concerns about weight gain. If concern about weight gain is a key barrier to quitting, it should be addressed simultaneously with quitting. Fiore MC, Bailey WC, Cohen SJ, et al. (2000). Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service.

Concerns about Withdrawal Symptoms Most pass within 2–4 weeks after quitting Cravings can last longer, up to several months or years Often can be ameliorated with cognitive or behavioral coping strategies Refer to Withdrawal Symptoms Information Sheet Symptom, cause, duration, relief Most symptoms peak 24–48 hours after quitting and subside within 2–4 weeks. As described in the Pharmacology of Nicotine and Principles of Addiction module, cessation is associated with a wide range of withdrawal symptoms. Specific symptoms included in the 4th edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; APA, 1994) are depression, insomnia, irritability/frustration/anger, anxiety, difficulty concentrating, restlessness, increased appetite/weight gain, and decreased heart rate. Cravings is a symptom of tobacco withdrawal that was included in the third edition and revised third edition of the DSM; however, this symptom was omitted from the DSM-IV classifications. Other symptoms of quitting have been described in the literature, and many of these are addressed in the Withdrawal Symptoms Information Sheet . When counseling a quitter, it is important to address concerns about withdrawal symptoms. The extent of withdrawal symptoms that a smoker experiences when abstinent from tobacco will be a function of his or her level of dependence. In general, the physiologic symptoms of withdrawal pass within 2–4 weeks after quitting (Hughes et al., 1991). However, some former tobacco users experience cravings for months or even years after quitting. These cravings typically are psychologically motivated, not physiologic, and can be ameliorated using cognitive or behavioral coping strategies. Sometimes a simple change of surroundings can help alleviate cravings, such as leaving the office to step outside for a breath of fresh air, or taking a quick walk up a flight or two of stairs to get some exercise. ♪ Note to instructor(s): At this time, direct students to pull out their one-page Withdrawal Symptoms Information Sheet. This handout describes each symptom, when it occurs after cessation, and potential coping methods. The Withdrawal Symptoms Information Sheet can be used as a resource for distribution to patients. American Psychiatric Association (APA). (1994). Diagnostic and statistical manual of mental disorders, 4th ed. Washington, DC: APA. Hughes JR, Gust SW, Skoog K, Keenan RM, Fenwick JW. (1991). Symptoms of tobacco withdrawal: A replication and extension. Arch Gen Psychiatry 48:52–59. HANDOUT

STAGE 3: PREPARATION Facilitate Quitting Process
Discuss methods for quitting Discuss pros and cons of available methods Pharmacotherapy: a treatment, not a crutch! Importance of behavioral counseling Set a quit date Recommend Tobacco Use Log Helps patients to understand when and why they use tobacco Identifies activities or situations that trigger tobacco use Can be used to develop coping strategies to overcome the temptation to use tobacco In facilitating the quitting process, clinicians should Discuss the pros and cons of different methods for quitting. It is important to elicit the patient’s point of view—each patient will have his or her own perceptions of the different methods. Encourage use of pharmacotherapy in addition to behavioral counseling. Many patients will feel that pharmacotherapy is a “crutch”—these patients should be advised that tobacco use is a chronic condition that alters brain chemistry and that, when feasible and not contraindicated, pharmacotherapy should be used because it increases the chances of quitting. It should be viewed as a treatment, not a crutch. Help the patient set a quit date. The quit date should be at least 3 days but not longer than 2 weeks from the current date. Recommend the Tobacco Use Log, if appropriate. This tool helps patients to identify moods, activities, or situations that trigger the desire to smoke or use other forms of tobacco. Triggers for tobacco use might include negative affect, being around other smokers, meal times, alcohol or coffee consumption, cravings for tobacco, stress, time pressures, or other situations such as celebrating with others. Triggers should be identified prior to quitting, while the patient is still smoking “normally.” Information gathered in the log can be used to develop coping strategies to overcome the temptation to use tobacco. ♪ Note to instructor(s): Have students refer to the Tobacco Use Log handout. The Tobacco Use Log is most appropriate for patients who are ready to quit, but it can be used with any patient who wants to learn more about his or her tobacco use behavior. This exercise provides important insight into the circumstances that underlie the need or desire for tobacco. Having a clear understanding of the behavior will help a person to be more effective when attempting to change it. Tobacco Use Log adapted from The Wrap Sheet and the Daily Cigarette Count (Wrap Sheet). In: The Washington State Pharmacists Association. (1997). “Smoking Cessation Training: Pharmacists Becoming Smoking Cessation Counselors,” pp. 3, 25. HANDOUT

STAGE 3: PREPARATION Facilitate Quitting Process (cont’d)
Tobacco Use Log: Instructions for use Continue regular tobacco use for 3 or more days Each time any form of tobacco is used, log the following information: Time of day Activity or situation during use “Importance” rating (scale of 1–3) Instructions for use: The Tobacco Use Log is a documentation tool that is kept with the patient’s tobacco. For example, the Tobacco Use Log could be folded and wrapped around the cigarette pack or can of snuff with a rubber band. The log should be readily available at the times when the patient uses the tobacco. Through careful documentation of tobacco use over a period of several days, patient-specific tobacco usage patterns become evident. Instruct the patient to continue his or her regular tobacco use for a period of at least 3 days (including one non–work day). It is preferable to complete the Tobacco Use Log for 7 consecutive days, because usage patterns may fluctuate as a function of the day of the week (e.g., weekends vs. work days). The patient should not attempt to reduce tobacco use during this time. The intent is to document current tobacco use habits and patterns. The following information should be noted in the Tobacco Use Log each time any form of tobacco is used: Time of day Brief description of the activity or situation while using the tobacco; other persons present at that time. Encourage the patient to think about the times and places where he or she uses tobacco, each time it is used. It is important for the patient to understand these cues so that effective coping strategies can be developed to overcome the temptation to use tobacco. Rating of the patient’s perceived importance of using the tobacco, at that time, using the following scale: 1 = Very important (would have missed it a great deal) 2 = Moderately important 3 = Not very important (would not have missed it) Log sheets should be reviewed prior to the quit attempt, to identify situations that trigger tobacco use and to develop coping strategies to prevent relapse. Cognitive and behavioral coping strategies are described in the slides that follow. Review log to identify situational triggers for tobacco use; develop patient-specific coping strategies

Discuss coping strategies Cognitive coping strategies Focus on retraining the way a patient thinks Behavioral coping strategies Involve specific actions to reduce risk for relapse HANDOUT The clinician and patient should discuss and develop effective cognitive and behavioral coping strategies for handling specific situations in which a person will be tempted to use tobacco. Research shows that using both cognitive and behavioral strategies increases a patient’s likelihood of quitting (Prochaska & DiClemente, 1992). These strategies are described in the next few slides. ♪ Note to instructor(s): Have students refer to the Coping with Quitting: Cognitive and Behavioral Strategies handout. This handout provides specific examples of coping strategies for various situations. Prochaska JO, DiClemente CC. (1992). Stages of change in the modification of problem behaviors. In: Progress in Behavior Modification, edited by Hersen M, Eisler RM, Miller PM. Sycamore, IL: Sycamore, pp. 184–218.

Cognitive Coping Strategies Review commitment to quit Distractive thinking Positive self-talk Relaxation through imagery Mental rehearsal and visualization Cognitive strategies focus on retraining the way a patient thinks. Many quitters panic because they are thinking about tobacco after they quit, and this leads to relapse. Thinking about cigarettes (or other forms of tobacco) is normal. The trick is not to dwell on the thought. As tobacco users move toward sustained abstinence, they learn to recognize that thinking about a cigarette doesn’t mean they need to have one. Some examples of cognitive strategies include the following: Review of one’s commitment to quitting can help, including reminding oneself that cravings and temptations are temporary and will pass. Sometimes it helps a patient to announce, either silently or out loud, “I want to be a nonsmoker, and the temptation will pass.” Or each morning, to look in the mirror and say, “I am proud that I made it through another day without tobacco!” Deliberate, distractive thinking can help the patient move current thought processes to issues other than craving or temptation to use tobacco. Positive self-talks, or “pep-talks,” involve saying things such as, “I can do this,” or reminding oneself of previous difficult situations in which tobacco use was avoided successfully. Relaxation through imagery helps the patient to center the mind on positive, relaxing thoughts. This can help to ease the anxiety, stress, and negative moods that may trigger tobacco use. Mental rehearsal and visualization involves envisioning situations that might arise and how best to handle them. This method is commonly used by athletes prior to a game. For example, a goalie might envision (or enact, during pregame warmups) how to block different types of shots or plays from opposing players. In the case of smoking, a person might envision what would happen if he or she were offered a cigarette by a friend—he or she would mentally craft and rehearse a response and perhaps even practice it by saying it out loud.

Cognitive Coping Strategies: Examples Thinking about cigarettes doesn’t mean you have to smoke one: “Just because you think about something doesn’t mean you have to do it!” Tell yourself, “It’s just a thought,” or “I am in control.” Say the word “STOP!” out loud, or visualize a stop sign. When you have a craving, remind yourself: “The urge for tobacco will only go away if I don’t use it.” As soon as you get up in the morning, look in the mirror and say to yourself: “I am proud that I made it through another day without tobacco.” This slide presents several examples of cognitive statements that can be used while quitting.

Behavioral Coping Strategies Control your environment Tobacco-free home and workplace Remove cues to tobacco use; actively avoid trigger situations Modify behaviors that you associate with tobacco: when, what, where, how, with whom Substitutes for smoking Water, sugar-free chewing gum or hard candies (oral substitutes) Take a walk, diaphragmatic breathing, self-massage Actively work to reduce stress, obtain social support, and alleviate withdrawal symptoms Behavioral strategies involved specific actions for coping with the effects of quitting and reducing risk for relapse. The effectiveness of these strategies may be patient specific, meaning that one technique will work better for some patients than for others. To determine which strategies work best for a specific patient, a clinician must understand the patient’s reasons for tobacco use and routines or situations with which tobacco use is associated. General approaches include enhanced control of the environment. Tobacco-free environments (e.g., home and workplace) can increase chances of success (e.g., Bauer et al., 2005; Chapman et al., 1999; Fichtenberg & Glantz, 2002). Patients should be advised to remove cues for tobacco use, modify behaviors associated with tobacco use, and actively avoid specific situations in which tobacco use is likely to occur. Oral substitutes for tobacco use include drinking water; chewing sugar-free gum; or sucking on hard, sugar-free candies. Taking walks helps to change the tobacco user’s environment and also increases circulation and oxygenation while burning calories. Deep breathing can have a relaxing effect, and research suggests that self-massage might reduce cravings (Hernandez-Reif et al., 1999). Social support is considered a key component of successful treatment plans (Fiore et al., 2000). Patients should be encouraged to call upon members of their support network as needed. Withdrawal symptoms are inevitable, especially with patients who are heavy users of tobacco products. It is important that clinicians educate their patients so that they know what to expect, how to alleviate specific symptoms, and how long to expect the symptoms to last. ♪ Note to instructor(s): Specific behavioral strategies for common cues or causes of relapse (stress, alcohol, other tobacco users, oral gratification needs, automatic smoking routines, postcessation weight gain, cravings for tobacco) are presented in the Coping with Quitting: Cognitive and Behavioral Strategies handout. Bauer JE, Hyland A, Li Q, Steger C, Cummings KM. (2005). A longitudinal assessment of the impact of smoke-free worksite policies on tobacco use. Am J Public Health 95:1024–1029. Chapman S, Borland R, Scollo M, Bronson RC, Dominello A, Woodward S. (1999). The impact of smoke-free workplaces on declining cigarette consumption in Australia and the United States. Am J Public Health 89:1018–1023 . Fichtenberg CM, Glantz SA. (2002). Effect of smoke-free workplaces on smoking behavior: systematic review. BMJ 325:188–191. Fiore MC, Bailey WC, Cohen SJ, et al. (2000). Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service. Hernandez-Reif M, Field T, Hart S. (1999). Smoking cravings are reduced by self-massage. Prev Med 28:28–32.

Provide medication counseling Promote compliance Discuss proper use, with demonstration Discuss concept of “slip” versus relapse “Let a slip slide.” Offer to assist throughout quit attempt Follow-up contact #1: first week after quitting Follow-up contact #2: in the first month Additional follow-up contacts as needed Congratulate the patient! It is imperative that clinicians counsel patients on their pharmacotherapy regimens (proper use, with demonstration as needed) and encourage patients to maintain close compliance with the prescribed regimen. Many cessation medications are designed to alleviate withdrawal; patients should be advised to take the medications as prescribed, not as needed. If a patient waits until he or she is in dire need of nicotine, it is too late. Nicotine replacement therapies do not have the same rapid onset of action as tobacco formulations. Prior to embarking on a quit attempt, the patient should be strongly advised not to smoke an occasional cigarette, or to have “just one drag” off of a friend’s cigarette. These are precursors for a full relapse. But, the patient should know the difference between a slip and a full relapse. A slip is a situation in which a person smokes one or just a few cigarettes. Although this can lead to a full relapse, it is not a complete failure, and it should be considered part of the learning process. If this occurs, encourage the patient to think through the scenario and determine the trigger(s) for smoking. Suggest coping strategies that will enable the patient to avoid smoking in similar situations. The last of the 5 A’s is to arrange follow-up. At this point, the clinician should summarize treatment plans and offer to assist throughout the quit attempt. Follow-up contact is recommended within the first week after quitting and a few weeks later (within the first month), with additional follow-up contacts as needed until the patient is stable in his or her new role as a nonuser of tobacco (Fiore et al., 2000). At follow-up contact, it is important to reassess the patient’s commitment to quitting and his or her confidence in quitting. The patient’s response will, in part, be a reflection of his or her confidence in the treatment plan. As needed, offer resources and referrals (e.g., to other health care providers, telephone cessation hotlines). Finally, congratulate the patient for making the important decision to quit. Fiore MC, Bailey WC, Cohen SJ, et al. (2000). Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service.

GOAL: Remain tobacco-free for at least 6 months.
ASSESSING READINESS to QUIT (cont’d) STAGE 4: Action Actively trying to quit for good Patients have quit using tobacco sometime in the past 6 months and are taking steps to increase their success. Withdrawal symptoms occur. Patients are at risk for relapse. The fourth stage in the continuum of change is action. In the action stage, patients have quit using tobacco sometime in the past 6 months. These patients are taking steps to enhance the likelihood that they can successfully quit by using medications such as nicotine replacement therapy. They dispose of unused cigarettes and remove lighters and other smoking apparatus from their homes and cars. They alter their routines to avoid habituated smoking patterns. These patients likely are experiencing changes and withdrawal symptoms—some pleasant (such as revived taste buds) and some not so pleasant (such as cravings, irritability, and weight gain). Recent quitters are at high risk for relapse. The goal is to help them remain tobacco-free. GOAL: Remain tobacco-free for at least 6 months.

HERMAN ® is reprinted with permission from
Some patients who recently quit soon begin to think of themselves as nonsmokers. HERMAN ® is reprinted with permission from LaughingStock Licensing Inc., Ottawa, Canada All rights reserved.

STAGE 4: ACTION Evaluate the Quit Attempt
Status of attempt Ask about social support Identify ongoing temptations and triggers for relapse (negative affect, smokers, eating, alcohol, cravings, stress) Encourage healthy behaviors to replace tobacco use Slips and relapse Has the patient used tobacco at all—even a puff? Medication compliance, plans for termination Is the regimen being followed? Are withdrawal symptoms being alleviated? How and when should pharmacotherapy be terminated? Recent quitters face many challenges in adopting their new behavior (not smoking). During the quit attempt, clinicians should carefully tailor interventions to match each patient’s needs. It is an opportunity to problem solve, or intervene, most creatively. Here are the basic strategies for evaluating a patient’s quit attempt: Inquire about available social support. Identify temptations and triggers relapse. Key triggers are negative affect, being around other tobacco users, eating, drinking alcohol, cravings for tobacco, and stress. Suggest coping strategies as needed, to remove or modify cues in the environment that make a person want to use tobacco, such as removing ashtrays, not entering an office where smokers are congregating, and not drinking alcohol if it will increase the likelihood of tobacco use. Encourage healthful behaviors to replace smoking (e.g., drinking water, exercise). Determine whether the patient has had any slips or has relapsed. Evaluate the treatment regimen. Is compliance with medications adequate? Are withdrawal symptoms being alleviated? How and when should pharmacotherapy be terminated?

STAGE 4: ACTION Facilitate Quitting Process
Relapse Prevention Congratulate success! Encourage continued abstinence Discuss benefits of quitting, problems encountered, successes achieved, and potential barriers to continued abstinence Ask about strong or prolonged withdrawal symptoms (change dose, combine or extend use of medications) Promote smoke-free environments Social support Discuss ongoing sources of support Schedule additional follow-up as needed; refer to support groups Relapse prevention is an important component of tobacco cessation interventions and should be part of every encounter with patients who recently quit using tobacco. At a minimum, the quitter should be congratulated for his or her successes and should be strongly encouraged to remain tobacco-free. Relapse prevention interventions should include a discussion of the patient’s perceived benefits of quitting, challenges during the process, successes achieved (specific situations in which the patient was tempted to use tobacco but resisted), and potential barriers to continued abstinence (e.g., depression, alcohol use, weight gain, stress, and other tobacco users who are not supportive of cessation). For patients who are feeling a sense of loss after quitting (some individuals feel as though they have lost a best friend), acknowledge their feelings and reassure them that the feelings will subside over time. Identify and recommend other activities that the particular patient views as rewarding. For patients who are complying with their pharmacotherapy regimens but continue to have strong or prolonged withdrawal symptoms, consider adding, combining, or extending use of medications. For a recent quitter, it is important to attempt to reduce relapse risk by promoting tobacco-free environments (e.g., in the home and workplace). Assess the patient’s level of ongoing support for the quit attempt. Schedule follow-up visits or calls, as needed to prevent relapse. If necessary, refer the patient to a tobacco cessation support group in the community.

GOAL: Remain tobacco-free for life.
ASSESSING READINESS to QUIT (cont’d) STAGE 5: Maintenance Tobacco-free for 6 months Patients remain vulnerable to relapse. Ongoing relapse prevention is needed. The final stage in the continuum of change is maintenance. Patients in the maintenance stage have been tobacco-free for at least 6 months. Nevertheless, they are still vulnerable to relapse. The strategies to be applied for patients in the maintenance stage are similar to, but less intensive than, those used for patients in the action stage. The goal for these patients is to remain tobacco-free for life. GOAL: Remain tobacco-free for life.

HERMAN ® is reprinted with permission from
Quitting is difficult, and tobacco users typically make multiple serious quit attempts before they are able to quit for good. For this reason, clinicians should routinely screen for periodic tobacco use among former users and continue to demonstrate support and encouragement for the patient’s continued success. HERMAN ® is reprinted with permission from LaughingStock Licensing Inc., Ottawa, Canada All rights reserved.

STAGE 5: MAINTENANCE Counseling Strategies
Assess status of quit attempt Slips and relapse Medication compliance, plans for termination Has pharmacotherapy been terminated? Continue to offer tips for relapse prevention Encourage healthy behaviors Congratulate continued success As with recent quitters, clinicians must evaluate the status of the quit attempt. Has the patient had any strong temptations to use tobacco, or any occasional use of tobacco products (even a puff)? Patients might be particularly vulnerable to relapse during times of extreme stress. Also, it is important to ensure that patients are appropriately terminating or tapering off of pharmacotherapy products. Relapse prevention strategies should be discussed as needed, and healthy behaviors should be encouraged—ones that the patient does not associate with tobacco use—such as exercise, hobbies (particularly ones that involve use of the hands), and going to movies with friends. To reduce weight gain, it is important for patients to maintain a healthy diet. Finally, patients who have been off of tobacco for 6 or more months should be congratulated for their enormous success. Staying tobacco-free is a continuous process of learning how to cope with the change. Clinicians should acknowledge, reward, and reinforce the patient’s triumphs in the face of this challenge. Continue to assist throughout the quit attempt. Remember: Behavioral change is a process, not a single step. It’s not uncommon for patients to experience at least one episode of relapse. This should not be regarded as a failure on the part of the patient or the provider, but rather one of the many possible steps within the process of establishing long-term change. Continue to assist throughout the quit attempt.

STAGES of CHANGE: A REVIEW
Quit date This diagram reviews the relationship between the stages of change as a function of time. - 6 months - 30 days + 6 months Precontemplation Contemplation Action Maintenance Preparation

COMPREHENSIVE COUNSELING: SUMMARY
Routinely identify tobacco users (ASK) Strongly ADVISE patients to quit ASSESS stage of change at each contact Tailor intervention messages (ASSIST) Be a good listener Minimal intervention in absence of time for more intensive intervention ARRANGE follow-up Use the referral process, if needed To summarize the 5 A’s approach (Fiore et al., 2000), clinicians should routinely identify tobacco users, strongly advise patients to quit, and assess stage of change at each contact. Patients who are not ready to quit should receive brief motivational interventions (the 5 R’s). In counseling patients, it is imperative that the clinician be a good listener and work with patients in designing treatment plans. When time is limited, a minimal intervention (ask and advise) should be administered. Follow-up is a key component of successful quit attempts. Refer patients to other health care providers, to cessation support groups, or to a toll-free quitline if needed. Fiore MC, Bailey WC, Cohen SJ, et al. (2000). Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service.

BRIEF COUNSELING: ASK, ADVISE, REFER
Brief interventions have been shown to be effective In the absence of time or expertise: Ask, advise, and refer to other resources, such as local programs or the toll-free quitline QUIT-NOW Brief interventions have been shown to be effective. In a meta-analysis of 17 trials assessing the effects of cessation advice from medical practitioners (Lancaster & Stead, 2004), brief advice was associated with an increased likelihood of quitting (odds ratio, 1.74) versus no advice (or usual care). When time or logistics do not permit comprehensive tobacco cessation counseling during a patient visit, clinicians are encouraged to apply a truncated 5 A’s model, whereby they Ask about tobacco use, Advise tobacco users to quit, and Refer patients who are willing to quit to a telephone quitline or other community-based resource for tobacco cessation. Telephone services that provide tobacco cessation counseling have proliferated over the past decade. These services provide low-cost interventions that can reach patients who might otherwise have limited access to medical treatment, because of geographic location or lack of insurance or financial resources. In clinical trials, telephone counseling services for smoking cessation have been shown to be effective in promoting quitting among the patients who use them (Ossip-Klein & McIntosh, 2003; Stead et al., 2003), and these positive results have been shown to translate into real-world effectiveness (Zhu et al., 2002). Additionally, preliminary evidence suggests that quitlines also are effective for spit tobacco cessation (Severson et al., 2000). With the fall 2004 introduction of a national toll-free quitline number (1-800-QUIT-NOW), all Americans now can receive tobacco cessation counseling at no cost. Even the busiest of clinicians can serve an important role by simply identifying tobacco users and referring them to a quitline for more comprehensive counseling. Lancaster T, Stead L. (2004). Physician advice for smoking cessation. Cochrane Database Syst Rev (4):CD Ossip-Klein DJ, McIntosh S. (2003). Quitlines in North America: Evidence base and applications. Am J Med Sci 326:201–205. Severson HH,et al. (2000). A self-help cessation program for smokeless tobacco users: Comparison of two interventions. Nicotine Tob Res 2:363–370. Stead LF, Lancaster T, Perera R. (2003). Telephone counselling for smoking cessation (Cochrane Review). Cochrane Database Syst Rev (1):CD Zhu SH, et al. (2002). Evidence of real-world effectiveness of a telephone quitline for smokers. N Engl J Med 347:1087–1093. This brief intervention can be achieved in 30 seconds.

WHAT IF… a patient asks you about your use of tobacco?
If a patient asks you whether you use tobacco or have used tobacco in the past, be honest. If you have never been a tobacco user, you really can’t understand how difficult it is to quit. But, being a health care provider, you understand the physiologic and psychosocial nature of addiction—which helps to provide insight. Clinicians counsel patients for all types of diseases without having the diseases themselves. It is appropriate to admit that, while you have not personally experienced quitting yourself, you have worked with plenty of patients who have. Acknowledge that it is a very difficult process. If you have been a tobacco user (or are a current user), then you probably have greater insight into the meaning of tobacco dependence. If you’ve tried to quit before (whether successfully or not), don’t assume that your patients’ experience with quitting will be similar to yours. It may be useful to provide some “this is what happened to me” insight, but don’t express an “I did it, so can you” attitude—this is not a sensitive approach to dealing with patients. Often, some of the best tobacco cessation counselors are individuals who used to use tobacco regularly. Current tobacco users are strongly encouraged to quit.

Sales of tobacco in pharmacies is an important issue that many believe casts a negative light on the pharmacy profession. The reasons that pharmacies cite for selling tobacco have been described as “weak and unconvincing” (Hussar, 2004). Evidence suggests that there is little public or professional support for tobacco sales in pharmacies. For example, in California, only 1.6% of licensed pharmacists (of 1,168 surveyed) and 2.0% of pharmacy students (of 1,518 surveyed) are in favor of tobacco sales in pharmacies. Furthermore, of 988 adult consumers interviewed, 72.3% disagreed with the statement “I am in favor of tobacco products being sold in drugstores,” and 83% stated that if the drugstore where they most commonly shopped were to stop selling tobacco products, they would shop there just as often, 14% would shop there more often, and 3% would shop there less often (Hudmon et al., under review). ♪ Note to instructor(s): Please engage your students in a discussion/debate about whether they believe it is appropriate for pharmacies to sell tobacco. Encourage students to have an opinion on this issue. ♪ Note to instructor(s): Please encourage students who are against tobacco sales in pharmacies to sign our online petition at Hudmon KS, Fenlon CM, Corelli RL, Schroeder SA, Prokhorov AV. (Under review). Tobacco sales in pharmacies: Time to quit. Hussar D. (2004, December 13). Let's get tobacco out of pharmacies! Drug Topics. Retrieved December 31, 2006, from Courtesy of Mell Lazarus and Creators Syndicate. Copyright 2000, Mell Lazarus.

The RESPONSIBILITY of HEALTH PROFESSIONALS
It is inconsistent to provide health care and —at the same time— remain silent (or inactive) about a major health risk. As a final note, it is important to emphasize that it is inconsistent, and perhaps unethical, to provide health care and—at the same time—remain silent (or inactive) about a major health risk. Addressing tobacco use is an essential component of clinical care. Promoting tobacco cessation is, in itself, an important component of therapy—it has immediate payoff in terms of both health improvements and cost savings (Lightwood & Glantz, 1997). The primary goal of the Rx for Change: Clinician-Assisted Tobacco Cessation program is to provide current and future health professionals with the knowledge and skills necessary to make an impact on the incidence of tobacco-related disease in the U.S. and abroad. Clinicians can make a difference (Fiore et al., 2000). Fiore MC, Bailey WC, Cohen SJ, et al. (2000). Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service. Lightwood JM, Glantz SA. (1997). Short-term economic and health benefits of smoking cessation: Myocardial infarction and stroke. Circulation 96:1089–1096. TOBACCO CESSATION is an important component of THERAPY.

DR. GRO HARLEM BRUNTLAND, FORMER DIRECTOR-GENERAL of the WHO:
“If we do not act decisively, a hundred years from now our grandchildren and their children will look back and seriously question how people claiming to be committed to public health and social justice allowed the tobacco epidemic to unfold unchecked.” This quote, from Dr. Gro Harlem Bruntland, former Director-General of the World Health Organization, is the closing remark in the 2001 Surgeon General’s report on women and smoking (USDHHS, 2001). It appropriately emphasizes the urgency of the need for clinicians and other health professionals to take a more active role in countering tobacco use. U.S. Department of Health and Human Services (USDHHS). (2001). Women and Smoking: A Report of the Surgeon General. Washington, DC: Public Health Service. USDHHS. (2001). Women and Smoking: A Report of the Surgeon General. Washington, DC: PHS.

ASSISTING PATIENTS with QUITTING A Transtheoretical Model Approach

Similar presentations

Presentation on theme: "ASSISTING PATIENTS with QUITTING A Transtheoretical Model Approach"— Presentation transcript:

Similar presentations

About project

Feedback

Log in

Auth with social network:

ASSISTING PATIENTS with QUITTING A Transtheoretical Model Approach

Similar presentations

Presentation on theme: "ASSISTING PATIENTS with QUITTING A Transtheoretical Model Approach"— Presentation transcript:

Similar presentations

About project

Feedback